Comprehending and adapting to fear of cancer recurrence in geriatric gastric cancer: A call for prehabilitation pathway

Abstract

Fear of cancer recurrence (FCR) is a psychological worry among cancer survivors, particularly among the elderly who are at risk of developing physiological and psychological vulnerabilities. In a cross-sectional survey of 264 elderly gastric cancer (GC) patients by Zhu et al, a high rate (63.64%) of clinically significant FCR was observed following laparoscopic radical gastrectomy. Factors affecting the high rate of FCR were a high level of self-perceived burden, lower education level, large tumour diameter, short duration of disease, and postoperative complications. They also established a validated nomogram model to predict the risk of FCR in this patient population. In this letter, we want to emphasize that, in addition to integrating psychological screening and focused interventions into the routine postoperative care of elderly GC patients, prehabilitation interventions before surgery, including psychological support, may provide a proactive response to mitigate FCR and improve long-term outcomes.

Key Words: Gastric cancer; Resilience; Psychological; Cancer recurrence; Stomach neoplasms; Prehabilitation; Postoperative care

Core Tip: Fear of cancer recurrence is highly prevalent (63.64%) among post-surgery elderly gastric cancer patients. Key risk factors include younger age, low education, larger tumors, complications, poor resilience, low support, and high perceived burden. A predictive nomogram can help identify high-risk patients. Integrating psychological support and prehabilitation before surgery can reduce fear of cancer recurrence and improve outcomes.

TO THE EDITOR

Gastric cancer (GC) is a major health burden, with a high prevalence among the elderly. The minimally invasive radical gastrectomy is nowadays a preferred choice to enhance the postoperative recovery and minimize perioperative complications. The psychological impacts, such as fear of cancer treatment and recurrence, namely fear of cancer recurrence (FCR), remain understudied. Many factors can exacerbate FCR, such as in the elderly, frailty, systemic medical conditions, and diminished psychological resilience. This letter emphasizes prehabilitation strategies, particularly those combining psychological support, patient education, and resilience training prior to surgery, in addition to integrating psychological screening and targeted interventions into routine postoperative care for elderly GC patients to reduce FCR and enhance long-term outcomes in this high-risk population[1-3].

Study details

The study by Zhu et al[4], recruited 264 elderly patients who underwent laparoscopic radical gastrectomy for GC. Participants were assessed with standard validated tools like the fear of progression questionnaire-short form, Connor-Davidson Resilience Scale, Social Support Rating Scale, and self-perceived burden scale. Multivariate logistic regression was employed to identify independent risk and protective factors. A predictive nomogram was subsequently developed and validated employing receiver operating characteristic curves, calibration plots, and decision curve analysis. The prevalence of clinically significant FCR (fear of progression questionnaire-short form score ≥ 34) was 63.64%. Independent protective factors included older age, greater psychological resilience, and higher levels of social support, while low educational attainment, larger tumour diameter, shorter illness duration, presence of postoperative complications, and elevated self-perceived burden emerged as significant risk factors. The nomogram of the predictive model demonstrated good discrimination (area under the curve = 0.82), calibration (Hosmer-Lemeshow; P = 0.722), and clinical utility (net benefit over 5%-95% risk threshold). The model achieved a sensitivity of 77% and a negative predictive value of 84%.

However, this study was also constrained by a few limitations that should be acknowledged. First, the single-center study design may limit the generalizability of the study findings, as the study population may not be representative of patients in other settings. Second, using a cross-sectional design restricts the ability to establish causal relationships between FCR and other variables, as data were collected at a single time rather than at different time points. Furthermore, cultural influences on self-reported psychological outcomes may have introduced reporting bias, potentially affecting the validity of the results. Thus, the study findings require external validation in diverse and larger cohorts to confirm their robustness and applicability. Longitudinal follow-up studies are necessary to explore the temporal dynamics and trajectory of FCR.

Though the authors have identified risk factors and protective factors for FCR, they did not suggest using the proposed nomogram model during the perioperative period. However, this nomogram may be used as a screening tool for preoperative risk stratification during the prehabilitation phase; thus, a patient-centric or personalized physiological prehabilitation can be created, guiding clinicians and institutions for resource allocation. Additionally, while the study identified the prevalence and associated factors of FCR, the authors did not discuss any interventions to reduce it. Thus, the author should have mentioned the need for future research to explore targeted interventions to manage and minimize FCR effectively.

FCR and role of prehabilitation

Although psychological care is being integrated into the cancer management programme, it is often considered in selected patients with psychological distress. During the postoperative period, implementing psychological therapies may be difficult. Thus, more importance is being given in the preoperative period to manage psychological distress in cancer patients. Prehabilitation is a multidisciplinary approach toward physical, emotional, and psychological optimization before surgery to improve postoperative outcomes. FCR can be addressed proactively by psychological and emotional prehabilitation, reducing the preoperative anxiety, increasing patients’ functional capacity, and psychological preparedness prior to surgery. Psychological prehabilitation, such as stress reduction, coping skills, resilience training, counselling and group support, has been found to enhance mental well-being and cancer-related anxiety pre- and postoperatively[1,2,5].

Psychological support during prehabilitation prepares patients psychologically for surgery. It focuses on setting realistic expectations and promoting active engagement in the postoperative period. Education during prehabilitation programs is designed to inform patients about the perioperative course, which includes guidance on nutrition, exercise/physical activity, smoking cessation, surgical procedure, associated risk factors, recovery process, expected hospital stay, and pain management. Depending on the patient’s literacy level, various interactive methods such as in-person discussion, videos, printed materials, and digital applications can be used to deliver educational content. When patients know what to expect, they are less likely to experience preoperative anxiety and are more likely to comply with perioperative instructions, leading to better postoperative outcomes.

Various psychological resilience training methods during prehabilitation such as cognitive behavioural therapy, relaxation training, mindfulness-based stress reduction (meditation, breathing exercises, etc.) can be employed to improve coping skills[6-9]. As the cancer care shifts toward more holistic and patient-centered care, integrating prehabilitation into standard cancer care pathways is essential. However, implementation of psychological prehabilitation remains limited and has challenges, including the lack of trained personnel, time constraints in the preoperative period, and low awareness among treating teams. Various Cultural factors and social stigma may also influence patients’ or family members’ willingness to engage in psychological support, e.g., stigma associated with psychological intervention among Asian elderly patients. Often, elderly individuals express psychological discomfort through physical symptoms, e.g., fatigue, headaches, rather than verbalizing distress, which may result in under-recognition of FCR and underutilization of psychological support services. Asian elderly patients may prefer discussing their fears with family members rather than with mental health professionals, who are viewed as a stigma. In addition, language barriers (e.g., inability to understand the patient’s language) may also cause underutilization of psychological support[10,11].

Conclusion

The published study highlighted FCR as a prevalent and clinically relevant issue among older patients recovering from laparoscopic resection for GC. Psychological hardness, social support, and burden perception are paramount in determining the outcome of FCR. Incorporation of routine psychological evaluation, risk stratification through use of nomogram instruments, and target psychosocial interventions into survivorship care plans could substantially enhance recovery and quality of life for the long term in this high-risk group. Of particular importance, prehabilitation, e.g., educational and psychological interventions begun before surgery, should be a standard part of oncologic management among the elderly. It may enhance resilience, reduce perceived burden, improve coping mechanisms and potentially reduce FCR and improve support for quality of survivorship. With the ageing population of cancer survivors in the world, FCR management is not only adjunctive but definitely essential to complete oncologic care. Multicentric randomized controlled trials comparing standard care with integrated prehabilitation programs could provide high-quality evidence for future policy change.